Provider Demographics
NPI:1811493604
Name:LEESTMA, KATRINA LOUISE (AMFT)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:LOUISE
Last Name:LEESTMA
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 ENCINAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2178
Mailing Address - Country:US
Mailing Address - Phone:831-469-1700
Mailing Address - Fax:831-425-1905
Practice Address - Street 1:380 ENCINAL ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2178
Practice Address - Country:US
Practice Address - Phone:831-469-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT110951101YM0800X, 106H00000X
CA628544101YM0800X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1811493604Medicaid